I have a patient with a single lumen non-power port that she has had for a little more than a year. We did have to declot once for lack of blood return, it is a bit tipped and can be hard to access, but no other problems. Friday she was in for a blood draw - I was able to draw 35 ml blood without any difficulty, a nice brisk return. I started to flush her and she complained of pain - burning and sharp - about 2 cm from the needle location - about where the connection between the catheter and the port is. I palpated the area with no evidence of problems, I still got a brisk blood return, and the pain only occurred when I was flushing. I thought that there might be a little leak at the connection, but did finish the flush and heparin so the catheter wouldn't clot. I wasn't sure that was the best idea but..... Anyhow she was able to return today, still has pain on flushing. She had a dye study that showed absolutely no problem. After the dye study she returned to me for a flush and lock of the port, and it continued to pain her. Anybody have any ideas? the port has been accessed several times this month, there are just 2 of us that access it and both have been successful on the first attempt.
Gail
Are you certain that the radiology dept took a close and careful look at the port pocket? Did they only focus on the catheter in the chest? This does sound like there is some type of pressure situation at or near the port body more than likely the junction of the port body and the catheter. The port tipping is a clue that something is happening inside that pocket. I hope this patient does not require any medications until you get it figured out. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I didn't talk with the radiologist, but he took a still picture of the pocket area, and checking it out later I didn't see anything that looked like a leak either. He didn't take any stills of the tip. It reportedly is deep in the SVC. The tilt has been stable for almost a year. Any other thoughts?
Gail
Gail McCarter, BSN,CRNI
Franklin, NH
A catheter dye study is performed by injecting dye into the catheter under fluoroscopy. This is the way to actually see leakage, retrograde flow, etc. A still picture is not enough. So I think your pictures are not showing what might be there. There is also no way you can adequately determine this conclusively simply by external examination. The pocket may be accommodating the leaking fluid so you do not see any edema. I would insist on a true catheter dye study before I used this catheter again. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn or anyone else with any ideas,
The port study in question was done under floroscopy. the Rad injected a total of 20 ml of dye, and was not able to detect any problems. The still picture I spoke about was taken during the floroscopy - the patient was complaining of the pain during the injection, and the pic was done and magnified to look for any subtle leak.
She is a person that has had lots of pain in her life and has little tolerance for pain (she'll admit it). I don't doubt her complaints, but don't know where else to look for an answer.
Gail
Gail McCarter, BSN,CRNI
Franklin, NH
Very strange situation. Is this port being used for any type of infusion or has it just been allowed to remain in place after completion of therapy just in case it is needed again? If it was a just in case situation, I would work toward getting it removed. Any catheter that is no longer medically necessary should be removed according to CDC, INS, etc. especially since this one is giving her problems. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I would consider getting a good PA/Lat CXR. I have seen PA views or even Fluro views appear to be Distal SVC and the lateral view showed placement in a small coladerial system that caused pain with flush.....Just a thought
Sorry...missed that you had already done a port-a-gram study....my bad!
Is the tilt of the port reservoir because it's against a bone or for some other reason? (yes, we once had a port the surgeon placed directly on top of the clavicle--port acted like a little teeter-totter.) Also, is it a subclavian vein placement or jugular? Is there any pain during "normal" infusions or just flushing? The reason I ask is that I have had experience with a non-tunneled cath that caused pain when flushing. There was also evidence of first rib pinch syndrome. So when a particular lumen (of the 3) was flushed, the colder temp of the fluid and the pressure of the expanded catheter against the bone caused her discomfort.
Thought you might like to know The patient returned for more labs. I was again able to access her easily, got a brisk blood return, and NO PAIN The only thing we could come up with for an explanation - she was babysitting a toddler for several days before the last visit, and the child would bang his head against her when he sat in her lap, and his head was at the level of her port. She thinks it might have been some bruising that was sensitive I'm not sure about that, but with the pain gone and the dye study showing no problem,I am more comfortable using this line.
Gail
Gail McCarter, BSN,CRNI
Franklin, NH
Glad you learned about this situation and that things are much improved. Thanks for sharing the outcome. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We had a similar situation where port flush would cause pain. This port was a problem from the start with pain with flushing but good blood return, dye study did not show any problems. Subsequent admissions for this patient, sometimes blood withdrawal problems, cathflo'd but took a long time to work. Then today blood return but unable to flush. Reaccessed and pt c/o pain with attempt to flush. I don't even want to cathflo it. Doctors to get surgery to assess again. What could cause blood return but inability to flush?
mahalo
For an implanted port there can be sludge consisting of blood and drug precipitate inside the reservoir of the port body. When you aspirate you pull this away from the outflow track or the place where the fluid flows from the reservoir into the catheter lumen. When you inject, this sludge is moved over the outflow track.
Where is this patient's pain on flushing? In the port pocket or near the catheter tip or somewhere else? Is it right or left sided insertion? Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you Lynn. It is a right sided port, the pain in near the port pocket. Sometimes pt c/o pain and then other times not. Had surgical docs look at it again and they feel it is fine. Reaccessed port again and then it seems to work again.
mahalo
It sounds like the port body could be close to a nerve. Pressure on the port body produces the pain. Of course, I would definitely rule out any leakage from this port by having contrast injected under fluoroscopy. Have you correlated the occurence of the pain to the type of medication being given? Someone could have stuck the catheter instead of the port body. Or there could be some coring in the silicone septum. All of these could produce leakage of what is being injected that could cause this pain. Or it could just be pressure from accessing the port body. Pain in the chest would be associated with issues with tip location. Left sided insertion can abut the right side of the vein wall causing vessel erosion and extravasation of fluid or medications. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861